Relationships between illness representations, physical activity and depression in chronic kidney disease

Background: Chronic Kidney Disease (CKD) is exacerbated by depression and confers significant healthcare costs. Whilst adverse impacts may be mitigated by physical activity, many patients with CKD remain physically inactive, with this physical inactivity potentially influenced by how CKD is appraised. Objectives: The study aims to explore the relationship between physical activity, depression and illness representations in CKD. Methods: Non-dialysing patients with CKD completed the Revised Illness Perception Questionnaire (IPQ-R), Beck Depression Inventory (BDI-II) and Short-Form International Physical Activity Questionnaire (IPAQ-SF) while demographic information was obtained via medical records. Correlation and regression analyses were conducted to determine the relationship of illness representations with levels of physical activity. Moderation and mediation analyses were performed to investigate the role of depression in any relationship between illness representations and physical activity levels. Results: Seventy respondents, with a mean age of 60 ± 16 years, the majority being male (60%), took part in the study. Of illness representation dimensions, personal control was positively associated with levels of physical activity (r=.288, p<.05) while timeline cyclical was a significant predictor (Beta=-.423, p=.008). Severity of depression was neither a moderator (b= .023, 95% CI [-.015, .061], t=1.201, p=.23) nor a mediator (b=-.021, BCa CI [-.082, .008], p=.33). Conclusions: Facets of illness representations had significant relationships with levels of physical activity. Future research concerning the development and validation of psychological interventions based on an illness representations framework for patients with CKD not on renal-replacement therapy is proposed. The efficacy of such interventions could be then evaluated using a randomised controlled method

‘Lost Voices’: The targeted hostility experienced by new arrivals

This thesis explores the ‘everyday’ lived realities of new immigrants, asylum seekers and refugees who experience a wide range of targeted victimisation, and highlights the emotional and behavioural impacts of those experiences on victims and the wider immigrant population. The study employs the concept of ‘super-diversity’ and develops an original empirical approach to exploring the racism, discrimination and targeted hostility experienced by new arrivals through this lens. This thesis provides a platform for the ‘hidden’ voices of particularly new arrivals from socially, culturally, economically and ethnically broad backgrounds to be heard and acknowledged in all their complexity. In particular, the research focuses on the ‘everyday’ incidents of microaggressions and infrequently discussed ‘micro-crimes’ that range from being insulted and ignored to harassment and threats of violence. By moving away from dominant, decades old perceptions of ‘race’ and ‘ethnicity’ and official definitions of hate crime, this research develops scope to ensure that the everyday experiences of people targeted because of their perceived nationality, legal status or ‘foreign’ identity are also captured. The study adopts a qualitative, flexible and reflexive approach that draws from interviews with new arrivals, participant observation and the supplementary use of ‘imaginative’ and non-conventional methods of data collection. The findings of this study highlight the pervasive nature of both direct and indirect targeted victimisation of new arrivals perpetrated by both White British residents and by members of the same or different ethnic minority community. The findings also reveal the importance of perceived ‘safe’ and ‘unsafe’ space, feelings of belonging and freedom of identity in shaping new arrivals’ sense of happiness in their host society. The findings also demonstrate how structural racism, discrimination and exclusion all serve to limit and restrict the opportunities and social mobility of new arrivals which ultimately has significant implications for their chances of wider, meaningful integration

Patient's perceptions of chronic kidney disease and their association with psychosocial and clinical outcomes: a narrative review

Patients with chronic kidney disease (CKD) form organized beliefs regarding their illness and treatment. These perceptions influence the coping strategies employed by an individual to manage his/her illness and may act as a predictor for his/her willingness to engage in self-management behaviours. While illness perceptions have been identified as predictors of non-adherence, depression and mortality in dialysis patients, there is a paucity of research in CKD patients not requiring renal replacement therapy. This narrative review synthesizes the existing literature regarding the role of illness perceptions and associated clinical and psychosocial outcomes in non-dialysis CKD patients. Studies were identified following database searches of AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, Medline, PsycINFO and Google Scholar in January 2016. Despite the small evidence base, existing studies indicate that negative illness perceptions are associated with disease progression and a number of psychosocial outcomes in non-dialysis CKD patients. Evidence from other clinical populations suggests that illness perceptions are modifiable through psychological intervention, which may be most effective if delivered early before beliefs have the chance to become more established. Therefore, targeting illness perceptions in the earlier stages of CKD may be optimal. Further studies are now required to ascertain the mechanisms through which illness perceptions predict psychosocial and clinical outcomes in CKD patients and to ultimately test the efficacy of illness perception-based interventions

Association of self-reported physical function with survival in patients with chronic kidney disease

Background: Reduced physical function is associated with an increased risk of mortality among CKD patients not requiring renal replacement therapy (RRT). Assessments of physical performance can help to identify those at risk for adverse events. However, objective measures are not always feasible and self-reported measures may provide a suitable surrogate. Methods: A cohort study examining associations between self-reported physical function and walking behaviour with survival in patients with CKD not requiring RRT. Data were analysed from the QCKD study (ISRCTN 87066351), a prospective observational mixed methods study of physical activity in patients with CKD. 450 CKD patients not requiring RRT, aged 17-93 years, were followed up for a median of 43 months. Upon enrolment, participants completed two questionnaires: Duke Activity Status Index (DASI) (physical function) and GP Physical Activity Questionnaire (habitual activity). Mortality data were collected from electronic records in September 2016; RRT was considered a competing event. Results: A total of 74 deaths occurred during follow-up and 101 participants were started on RRT. The adjusted subdistribution hazard ratio (SHR) of mortality in participants scoring >19.2 on DASI was 0.51 (95% CI, 0.30-0.88) while a 1-unit increase in DASI was associated with SHR 0.97 (0.95-0.99). The adjusted SHRs of mortality were 0.48 (0.26-0.90), 0.25 (0.11-0.57), and 0.48 (0.23-0.80) for participants walking <1, 1-3 and ≥3 hours per week, 3 respectively, compared to no walking. Walking pace >3mph was associated with reduced risk of mortality [SHR 0.37 (0.20-0.71)] compared to walking pace <3mph. Conclusions: Physical function and walking behaviours were independently associated with survival in CKD and may help to identify patients at risk for adverse events

12-weeks combined resistance and aerobic training confers greater benefits than aerobic alone in non-dialysis CKD.

There is a growing consensus that chronic kidney disease (CKD) patients should engage in regular exercise, but there is a lack of formal guidelines. In this report, we determined whether combined aerobic and resistance exercise would elicit superior physiological gains, in particular muscular strength, compared to aerobic training alone in non-dialysis CKD. Non-dialysis CKD patients stage 3b-5 were randomly allocated to aerobic exercise (AE, n=21; 9 males; median age 63years [IQR, 58-71]; median eGFR 24[IQR, 20-30] mL/min/1.73m2) or combined exercise (CE, n=20, 9 males, median age 63years [IQR, 51-69], median eGFR 27[IQR, 22-32] mL/min/1.73m2), preceded by a 6-week run in control period. Patients then underwent 12-weeks of supervised AE (treadmill, rowing or cycling exercise) or CE training (as AE plus leg extension and leg press exercise) performed 3x/week. Outcome assessments of knee extensor muscle strength, quadriceps muscle volume, exercise capacity and central haemodynamics were performed at baseline, following the 6-week control period and at the end of the intervention. AE and CE resulted in significant increases in knee extensor strength of 1619% (P=0.001) and 4837% (P<0.001) respectively, which were greater after CE (P=0.02). AE and CE resulted in 57% (P=0.04) and 97% (P<0.001) increases in quadriceps volume respectively (P<0.001) which was greater after CE (P=0.01). Both AE and CE increased distance walked in ISWT (2844m; P=0.01 and 3245m P=0.01) respectively. In non-dialysis CKD, the addition of resistance exercise to aerobic exercise confers greater increases in muscle mass and strength than aerobic exercise alone

The association of physical function and physical activity with all-cause mortality and adverse clinical outcomes in non-dialysis chronic kidney disease: a systematic review.

Objective: People with non-dialysis dependent chronic kidney disease (CKD) and renal transplant recipients (RTR) have compromised physical function and reduced physical activity (PA) levels. Whilst established in healthy older adults and other chronic diseases, this association remains underexplored in CKD. We aimed to review the existing research investigating poor physical function and PA with clinical outcome in non-dialysis CKD. Data sources: Electronic databases (PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials) were searched until December 2017 for cohort studies reporting objective/subjective measures of PA/physical function and the associations with adverse clinical outcomes/all-cause mortality for patients with non-dialysis chronic kidney disease stages 1 to 5 and RTR. The protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42016039060). Review methods: Study quality was assessed using the Newcastle-Ottawa Scale and the Agency for Healthcare and Research Quality (AHRQ) standards. Results: 29 studies were included; 12 reporting on physical function and 17 on PA. Only 8 studies were conducted with RTR. The majority were classified as “Good” according to the AHRQ standards. Although not appropriate for meta-analysis due to variance in the outcome measures reported, a coherent pattern was seen with higher mortality rates and/or prevalence of adverse clinical events associated with lower PA and physical function levels, irrespective of the measurement tool used. Sources of bias included incomplete description of participant flow through the study and over-reliance on self-report measures. Conclusions: In non-dialysis CKD, survival rates correlate with greater PA and physical function levels. Further trials are required to investigate causality and the effectiveness of physical function/physical activity interventions in improving outcomes. Future work should identify standard assessment protocols for PA and physical function